Basic Information
| Provider Information | |||||||||
| NPI: | 1225649122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | MACKENZIE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 913 2ND ST S APT 306 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322506578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503450902 | ||||||||
| FaxNumber: | 8503450902 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 PONTE VEDRA PARK DR | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320826600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2020 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT36038 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.